VICTIM REPORTING PREFERENCE STATEMENT …

1 DSAID CASE NUMBER:1. REPORTING PROCESS AND OPTIONS DISCUSSED WITH THE SAPR VA OR SARCAUTHORITY: 10 113 note, Department of Defense Policy and Procedures on Prevention and Response to Sexual Assaults Involving Members of the Armed Forces; 10 136; 32 ; DoD Directive ; DoD Instruction ; 10 3013; Army Regulation 600-20, Chapter 8; 10 5013; Secretary of the Navy Instruction ; Marine Corps Order ; 10 8013; Air Force Instruction 36-6001; and 9397 (SSN), as amended. PRINCIPAL PURPOSE(S): Information will be used to document elements of the sexual assault response and/or REPORTING process and comply with the procedures set up to effectively manage the sexual assault prevention and response program. At the local level, Service SAPR Program Management, Major Command Sexual Assault Response Coordinator(s) (SARCs), Installation and Brigade SARCs use information to ensure that victims are aware of services available and have contact with medical treatment personnel and DoD law enforcement entities.

2 At the DoD level, only de-identified data is used to respond to mandated congressional REPORTING requirements. The DoD Sexual Assault Prevention and Response Office has access to identified closed case information and de-identified, aggregate open case information for congressional REPORTING , study, research, and analysis purposes. Collected information is covered by DHRA 06 DoD, Defense Sexual Assault Incident Database ( ). ROUTINE USE(S): The DoD blanket routine uses found at may apply to this record. Note: Any release made as a blanket routine use will be consistent with the principal purpose of its original collection. DISCLOSURE: Voluntary. However, if you decide not to provide certain information, it may impede the ability of the SARC to offer the full range of care and support established by the Sexual Assault Prevention and Response program. You will not be denied advocacy services or healthcare (medical and mental health) because you selected the Restricted REPORTING option.

3 The Social Security Number (SSN) is one of several unique personal identifiers that may be provided. This form will be retained for 50 ACT STATEMENTVICTIM REPORTING PREFERENCE STATEMENT (Read Privacy Act STATEMENT before completing this form .)(1) I understand that law enforcement and my command will be notified that I am a VICTIM of sexual assault. An investigation into the crime will be started by a Military Criminal Investigation Organization (MCIO) investigator ( CID, NCIS, AFOSI) or the appropriate civilian law enforce- ment. I can receive medical treatment, support services, and counseling. I can also choose to have a Sexual Assault Forensic Examination (SAFE) if indicated. In a UCMJ case, I will be provided a DD form 2701 (which contains important information about my rights as a VICTIM ) from the law enforcement or MCIO. I should retain the DD form 2701. In accordance with DoD policy, if REPORTING a sexual assault that occurred prior to or while not performing active service or inactive training, National Guard and Reserve Component members are eligible to receive SAPR advocacy support services from a SARC and a SAPR VA and are eligible to file both a Restricted or an Unrestricted UNRESTRICTED REPORTING - REPORTING A CRIME WHICH IS the opportunity to talk with a Sexual Assault Prevention and Response VICTIM Advocate (SAPR VA) or a Sexual Assault Response Coordinator (SARC) before selecting a REPORTING option.

4 , and (DoD Identification Number) (Social Security Number)a. I, (full name)(5) If the crime is prosecuted under the Uniform Code of Military Justice (UCMJ), any communication with my SARC or SAPR VA are confidential under the VICTIM - VICTIM Advocate Privilege unless an exception applies.(3) Depending on the facts of my case, I may request a Military Protective Order (MPO). If a written and/or verbal MPO is issued against a service member, my commander will provide me with a copy of the DD form 2873.(4) I also have the option of requesting a Civilian Protective Order (CPO) from civilian courts.(1) The SARC or SAPR VA has explained to me the services, protective orders, and REPORTING options that are available to me.(2) The SARC or SAPR VA explained to me that if my case is prosecuted in a civilian jurisdiction there will be different procedures in place, , SAFE kit retention and DD form 2701.

5 (3) Please initial here if this sexual assault occurred PRIOR TO ENTRY into military service. (Iincludes both as a child or adult.)(2) In accordance with DoD Instruction (DoDI) , as a service member, I understand that (through a separate form ) I may request an Expedited Transfer (temporary or permanent) from my installation or to a different location within my installation.(3) I understand the evidence collected from my SAFE will be stored for 5 years from the date I sign this form , if the SAFE was conducted at a Military Treatment Facility. If the evidence is collected by a civilian healthcare facility, the civilian healthcare facility will handle the SAFE kit storage in accordance with the established Memorandum of Understanding (MOU) with the DoD. I will be contacted in 1 year by my SARC to discuss my options as they relate to this evidence. If the SAFE was conducted by a civilian facility with no formal MOU with DoD, then the SAFE kit will be handled in accordance with state and local laws.

6 (2) I understand that there are exceptions to Restricted REPORTING (see Page 2) and they have been explained to me. If an exception applies, the details of my assault may be disclosed.(1) I understand that l may confidentially receive medical treatment, advocacy services, legal services, and counseling. I may also choose to have a Sexual Assault Forensic Examination (SAFE), if indicated. Law enforcement and my command will NOT be notified. My report will NOT cause an investigation of the crime. No action will be taken against the offender(s) as the result of my report. If REPORTING a sexual assault that occurred prior to or while not performing active service or inactive training, National Guard and Reserve Component members are eligible to receive SAPR advocacy support services from a SARC and a SAPR VA and are eligible to file both a Restricted Report and an Unrestricted RESTRICTED REPORTING - CONFIDENTIALLY REPORTING A CRIME WHICH IS NOT INVESTIGATED.

7 (4) All state laws, local laws or international agreements that may limit some or all of DoD's Restricted REPORTING protections have been explained to me. In the (state, city/county of _____ , medical authorities must report the sexual assault to _____ .(5) I understand that the SARC will provide information that does not reveal my identity, nor that of my alleged offender, to the installation commander. This notification takes place within 24 hours of my Restricted Report. If I may be at a deployed location or there are extenuating circumstances, the notification will be made within 48 hours. Commanders require this information for public safety and other responsibilities.(6) I understand that certain protective actions, such as a Military Protective Order and/or a Civilian Protective Order against the alleged offender, or an Expedited Transfer and my VICTIM 's rights, will NOT be available to me if I choose Restricted Designer EDITION IS form 2910, JUN RESTRICTED REPORTING (Continued)(1) I understand that if I do not choose a REPORTING option right now or if I refuse to sign this form , the SARC or SAPR VA has no obligation to inform investigators or commanders about my sexual assault.)

8 The SARC or SAPR VA may only disclose information about our conversation according to the exceptions to the VICTIM - VICTIM Advocate OTHER IMPORTANT CONSIDERATIONS FOR UNRESTRICTED AND RESTRICTED REPORTS2. CHOOSE A REPORTING OPTION (Initial)INITIALS(2) I understand that I have the right to decline any or all SAPR services. I may also ask for a different SAPR VA if one is I elect Unrestricted REPORTING . I have decided to report that I am a VICTIM of sexual assault to my command, law enforcement, or other military authorities for investigation of this crime. I understand that a Restricted Report is no longer available to I have reconsidered my previous selection of Restricted REPORTING and am now choosing to make an Unrestricted I elect Restricted REPORTING . I have decided to confidentially report that I am a VICTIM of sexual assault. Law enforcement or other military authorities will NOT be notified unless one of the exceptions applies.

9 I understand the information I provide will NOT start an investigation or be used to hold the alleged offender(s) appropriately accountable. I understand that I can convert to Unrestricted REPORTING at any time.(3) I have been advised to keep a signed and dated copy of this form for my records. This form may be used in other matters before other agencies ( , Department of Veterans Affairs) or for other lawful purposes. Restricted Reports: By signing this form I am giving consent that for Restricted Reports, this form will be retained for 50 years, as required by law. For Restricted Reports, the law requires that this form is retained in a manner that protects confidentiality. Unrestricted Reports: By signing this form I am giving consent that for Unrestricted Reports, this form will be stored electronically in DSAID for 50 years. For Unrestricted Reports, access to it will be limited to persons with an official need to know.

10 (4) I understand that I cannot request an Expedited Transfer, a Military Protective Order, or a Civilian Protective Order through this form .(6) I understand that if I experience coercion, retaliation, reprisal, or ostracism from my supervisors or peers, I can report it to the SARC, Special victims Counsel, my commander, VICTIM Witness Assistance Program personnel or my Service Inspector General.(7) I understand that I can also request a defense counsel to advise and assist me in the event that there is evidence that I committed misconduct around the time of the sexual assault allegation (for example, underage drinking).(5) I understand that I am eligible for a Special victims Counsel, who will be my attorney and not the government's attorney, and who will provide me with legal advice and representation. RESTRICTED REPORT CASE SIGNATURE OF VICTIM6. VICTIM CONSENTED TO TRANSFER OF (RR/UR) CASE DOCUMENTS TO ANOTHER SARC: (X and complete as applicable)If yes: Date (YYYYMMDD)NoYes9.